I declare I have collected signatures and am willing to authenticate and verify that the aforementioned signatures were collected and are being reported with the authority of the subscribers to the petition.

(By typing your name above, you agree that it is valid as your signature.)

[Mandatory fields:]

City, State, Zip Code:
Telephone No:

We will keep your personal information above confidential and will only use it internally to contact you to verify the signatures you have collected.